Case files psychiatry - part 7 pps

274 CASE FILES: PSYCHIATRY ANSWERS TO CASE 33: Histrionic Personality Disorder Summary: A 42-year-old man comes to a psychiatrist with complaints of a depressed mood and difficulty sl

272 CASE FILES: PSYCHIATRY

•> CASE 33

A 42-year-old man comes to see a psychiatrist stating that his life is "crashing down around his ears." He explains that since his girlfriend of 2 months left him, he has been "inconsolable." He says that he is having trouble sleeping at night because he is mourning her loss When asked to describe his girlfriend, the patient states, "She was the love of my life, just beautiful, beautiful." He is unable to provide any further details about her He says that they had five dates, but that he simply knew that she was the one for him He claims that he was often in the "depths of despair" in his life, but that he also felt "on top of the world." He denies any psychiatric history or any medical problems

On a mental status examination, the patient is dressed in a bright, pattern shirt and khaki pants He leans over repeatedly to touch the interviewer

tropical-on the arm as he speaks, and he is cooperative during the interview He some­times sobs for a short period of time when talking directly about his girlfriend but smiles broadly during the interview when asking the interviewer questions about herself His speech is of normal rate, although at times somewhat loud The patient describes his mood as "horribly depressed." His affect is euthymic the majority of the time, and full-range His thought processes and thought content are all within normal limits

• What is the most likely diagnosis?

• What is the best initial treatment for this patient?

274 CASE FILES: PSYCHIATRY

ANSWERS TO CASE 33: Histrionic Personality Disorder

Summary: A 42-year-old man comes to a psychiatrist with complaints of a

depressed mood and difficulty sleeping His says that his girlfriend recently left him Although he is obviously upset about the loss of the relationship,

he cannot describe her in any specific detail, and they had not been going out together for long The patient's speech and manner appear somewhat theatrical and overblown His affect appears euthymic and full-range, and

he appears to be trying to directly engage the (female) interviewer by touch­ing her and asking her direct personal questions In this manner, he appears

to be trying to draw attention to himself by being somewhat seductive He

is shown to have normal thought processes and thought content on a men­tal status examination

• Most likely diagnosis: Histrionic personality disorder

• Best initial treatment: Supportive psychotherapy while he grieves the

loss of his girlfriend Setting a strict limit on his seductive behavior needs to be implemented as well

Analysis Objectives

1 Recognize histrionic personality disorder in a patient

2 Know the treatment recommendations for patients with this disorder who come in while experiencing some kind of psychologic crisis

Considerations

This patient provides a somewhat classic presentation of histrionic person­ality disorder Newer epidemiological evidence suggests that histrionic personality disorder is equally common in men as in women, affecting approximately 1.8% of Americans Clues to making the diagnosis include

his theatrical and overblown speech and his seductive manner Other

clues include the fact that although he describes himself as being deeply depressed about the loss of his girlfriend, he is unable to describe her other than superficially, and his affect appears euthymic His case is not unusual because patients with this disorder come to a psychiatrist with a depressed mood but rarely with the thought that their difficulties in functioning in daily life and work are secondary to their own maladaptive behaviors

275

CLINICAL CASES

Definitions

Dissociation: A defense mechanism by which an individual deals with

emotional conflict or stressors with a breakdown in the usually inte­grated functions of consciousness, memory, perception of self or the environment, or sensory/motor behavior For example, a woman who has just been told that her child was killed in an automobile accident suddenly feels as if she is not herself but rather is hearing the events unfold as if they are being told to "someone else."

Limit setting: An activity by which a physician clearly tells a patient what

is, and what is not appropriate behavior in a given circumstance For example, a physician can set limits on how many times a patient can telephone the physician in a week

Repression: A defense mechanism by which individuals deal with emo­

tional conflict or stressors by expelling disturbing wishes, thoughts, or experiences from their conscious awareness For example, a patient is told that she has breast cancer and clearly hears what she has been told because she can repeat the information back to the physician However, when she returns home later, she tells her husband that the visit went well but that she cannot remember what she and the physician spoke about during the appointment

Supportive psychotherapy: Therapy designed to help patients support

their existing defense mechanisms so that their functioning in the real world improves Unlike insight-oriented psychotherapy, its goal is to maintain, not improve, a patient's intrapsychic functioning

Clinical Approach

Patients with histrionic personality disorder show a pervasive pattern of excessive emotionality and attention seeking They are uncomfortable in

settings where they are not the center of attention Their emotions are rap­

idly shifting and shallow, and they often interact with others in a seductive manner Their speech is impressionistic and lacks detail They are dra­ matic and theatrical and exaggerate their emotional expressions They

often consider relationships to be much more intimate than they really are They are suggestible to the thoughts of others as well, often adopting other's views without thinking them through

276 CASE FILES: PSYCHIATRY

Differential Diagnosis

Patients with borderline personality disorder can often appear similar to those with histrionic personality disorder, although the former make suicide attempts more often and experience more frequent (brief) episodes of psy­chosis Patients who are manic can often be overly dramatic, attention seeking, and seductive, but symptoms of insomnia, euphoria, and psychosis are present

as well

Interviewing Tips and Treatment

The clinician should provide emotional support for and show interest in these

patients but should not allow a personal or sexual relationship to form Tactful confrontation about seductive behavior can help Expressing admi­

ration of the patient, without showing inappropriate behavior, can help in forming a therapeutic working alliance The treatment of histrionic personal­ity disorder is often best attempted in a group therapy setting, where such patients, particularly if there are other patients with the same diagnosis in the group, better tolerate confrontations to avoid being rejected by other group members Most psychotherapies require insight, which these individuals lack Dynamic psychotherapy would likely lead to tumultuous results at best

Comprehension Questions

[33.1] A 35-year-old woman with histrionic personality disorder has seen her psychotherapist once a week for the past year During a session, the therapist tells the patient that he is going to be on vacation the follow­ing 2 weeks When he returns from the vacation, the patient tells him that she felt he abandoned her and says, "You didn't even bother to tell

me that you would be away." This lapse in memory can best be described as which defense mechanism common to patients with histri­onic personality disorder?

277

CLINICAL CASES

[33.3] A 20-year-old woman comes to see a psychiatrist at the insistence of her mother, who states that her daughter just "isn't herself." The patient has dressed in brightly colored clothes and worn large amounts of makeup for the past 3 weeks She acts overtly seductive toward her col­leagues at work, is more distractible, and is easily irritated She also sleeps less, claiming that she "no longer needs it." Which of the fol­lowing diagnoses best fits this patient's presentation?

A Histrionic personality disorder

B Borderline personality disorder

C Bipolar disorder, mania

D Narcissistic personality disorder

In interacting with these patients, the physician should use a key, friendly approach but should watch interpersonal bound­aries He or she should not become caught up in personal or sexual relationships with such patients, who can be quite seductive

low-278 CASE F I L E S : PSYCHIATRY

Patients with histrionic personality disorder can be differentiated from

I those with mania because the latter often develop dramatic, seduc­

tive symptoms as new-onset behavior, not as a pervasive pattern Patients with mania commonly also have vegetative symptoms, such as a decreased need for sleep, and psychotic symptoms as well

< • C A S E 3 4

A 9-year-old girl is brought to her pediatrician by her mother because of fre­quent complaints of headaches and stomachaches for the past 3 to 4 weeks The mother tells you that she has also been doing worse in school during this same time period and believes it is a result of the chronic aches She has already taken her to the optometrist, and her vision is not a problem On fur­ther questioning by the medical student, we find out that the child's father is part of the army reserve and left for a 6-month assignment in Iraq 5 weeks ago

He e-mails her almost daily, but his daughter notes how much she worries about him and whether he is safe or not When interviewed, the girl also notes that in addition to her worries about her father, she also sometimes cries about

it and feels better when she talks to her friends She occasionally has a bad dream about her father and feels she sleeps more uneasily as a result

• What is the most likely diagnosis for this patient?

• What is the treatment of choice for this disorder?

280 CASE FILES: PSYCHIATRY

ANSWERS TO CASE 34: Adjustment Disorder

Summary: A 9-year-old girl presents to her pediatrician with a number of

short-term (3-4 weeks) somatic complaints In addition, she also has some mild symptoms related to mood as well as anxiety as a result of her father's army commitment She is able to maintain general functioning, but there does seem to be some decline She shows evidence of good strengths in that she can express these feelings to others and feels better as a result

+ Most likely diagnosis: Adjustment disorder with mixed anxiety and

depressed mood

• Treatment of choice: Psychotherapy (supportive)

Analysis Objectives

1 Recognize adjustment disorder in a patient

2 Understand the best treatment recommendation for patients wilh this disorder

Considerations

A few weeks after her father was sent overseas to fulfill an armed-service obli­gation his daughter begins to have some difficulties noted by her modier These seem to show up first in terms of somatic complaints This is a common presen­tation for anxious or depressed feelings in children These should be worked up

to reassure both the parents and the patients that there is nothing physically seri­ously wrong When further investigated, we find that she has additional, more classically psychiatric symptoms in the areas of mood and worries She is func­tioning adequately, but there does seem to be a mild decline The symptoms have been short in duration (less than 6 months) and occurred within 4 months of the stressor (father going overseas) Her prognosis is good, given her supportive environment and responsiveness to talking about her feelings (See the diagnos­tic criteria in Table 34—1.) Supportive therapy would be indicated in this situation

as well as an evaluation of the mother to see how she is managing

A P P R O A C H T O A D J U S T M E N T D I S O R D E R

Definitions

Clinically significant symptoms: Distress in excess of what might be

expected in response to the particular stressor in question To be consid­ered clinically significant, these symptoms must include a marked impact on functioning in a variety of settings

2 Clinically significant symptoms developed as a response to the stressor

,v The symptoms do not persist longer than 6 months alter the stressor is resolved

4 Five different subtypes of adjustment disorder are recognized, each characterized

Conduct: When used clinically, this term relates to the psychopathology

associated with a conduct disorder The hallmark of this disorder includes violation of the rights of others

Supportive psychotherapy: A type of therapy in which individuals are

taught how to confront issues such as phobias and stressors

Clinical Approach

Differential Diagnosis

The largest concern in the differential diagnosis for patients with adjustment disorder is major depression The difference between the two is a matter of degree Patients with major depression can see its onset following the onset of

a stressor, although even after the stressor is removed, the major depression continues Also, in major depression, marked difficulties involving sleep, appetite, concentration, and energy level are noted, and suicidal ideation (not just transient) and psychotic symptoms can occur In children or adolescents, irritable mood is often seen rather than the classic depressed mood seen in adults Mood disorders arising secondary to the u.se of a substance or a general medical condition must always be ruled out Clinicians should exclude any symptom complexes characteristic of other stress-induced disorders as well (such as in acute stress disorder or posttraumatic stress disorder [PTSD]) before diagnosing adjustment disorder With PTSD the stressor is usually actual or threatened death or serious injury Finally, normal grief reactions or bereavement can be difficult to differentiate from adjustment disorders, but if the stressor is within expected and/or culturally acceptable ranges, adjustment disorder should generally not be diagnosed

282 CASE FILES: PSYCHIATRY

Treatment

The treatment of choice for adjustment disorder is psychotherapy Group

psychotherapy can often be helpful, especially if the group members all have sim­ilar stressors, for example, patients with breast cancer or individuals who have experienced a similar trauma Individual therapy gives patients an opportunity to work through the meaning of the stressor in their lives and the impact it has on their emotional well-being Medications are not, in general, indicated, although short-term medications to induce sleep can be helpful if sleep disturbance is part

of the symptom presentation Finally, in the case of extremely acute stressors, for example, a specific traumatic event such as a car accident or an incidence of vio­lence, supportive techniques such as relaxation training, reassurance, and envi­ronmental modification (e.g., changing the locks on an apartment door, or moving, if a patient has been the victim of an in-home rape) can be helpful

Comprehension Questions

[34.1] Adjustment disorder is diagnosed in a 45-year-old woman who was fired from a job she held for 20 years She undergoes supportive psy­chotherapy Nine months later, she is seen by her physician, but none

of her symptoms have resolved During this time, she found another job that is similar to her first position in duties and salary Which of the following is the most likely diagnosis?

A Adjustment disorder

B Posttraumatic stress disorder

C Major depressive disorder

E Behavioral modification therapy

[34.3] In a child who comes in with a diagnosis of major depression, which

of the following is the most likely symptom that you might see instead

283

CLINICAL CASES

Answers

[34.1) C The duration requirement for symptoms occurring after the stressor

resolved are met

[34.2] A Symptoms accompanying this disorder most likely will be resolved with a decrease in or elimination of the stressor Brief supportive psy­chotherapy is indicated to help the patient deal with the response to the stressor

[34.3] A In the clinical presentation of children and adolescents, one will often find evidence of irritability or short temper rather than a feeling

of sadness or depression The ability to understand the concept of depression seems to be developmentally mediated

CLINICAL PEARLS

Adjustment disorder has several different subtypes of symptoms: depressed mood, anxiety, or disturbance of conduct

Children often feel irritable rather than depressed

The chronology of the symptoms is very important in making the correct diagnosis

The most important treatment modality for adjustment disorder involves psychotherapy and not a somatic intervention

•> CASE 35

A 41-year-old nurse presents to the emergency department with concerns that she has hypoglycemia from an insulinoma She reports repeated episodes of headache, sweating, tremor, and palpitations She denies any past medical prob­lems and only takes nonsteroidal anti-inflammatory medications for menstrual cramps On physical examination, she is a well-dressed woman who is intelligent, polite, and cooperative Her vital signs are stable except for slight tachycardia The examination is remarkable for diaphoresis, tachycardia, and numerous scars

on her abdomen, as well as needle marks on her arms When asked about this, she says that she feels confused because of her hypoglycemia

The patient is subsequently admitted to the medical service Laboratory evaluations demonstrate a decreased fasting blood sugar level and an increased insulin level, but a decreased level of plasma C-peptide, which indicates exogenous insulin injection When she is confronted with this information, she quickly becomes angry, claims the hospital staff is incompetent, and requests that she be discharged against medical advice

• What is the most likely diagnosis?

• How should you best approach this patient?

286 CASE FILES: PSYCHIATRY

ANSWERS TO CASE 35: Factitious Disorder

Summary: A 41-year-old female health care worker presents to the emer­

gency department with symptoms typical of an insulinoma, including headache, diaphoresis, palpitations, and tremors She denies a medical his­tory, although her physical examination demonstrates prior surgeries and injections When confronted with this evidence, she becomes hostile and asks

to leave the hospital

• Most likely diagnosis: Factitious disorder

• Best approach: In order to engage the patient in psychiatric treatment

attempt to ally with her regarding her compulsion to "be sick."

Analysis Objectives

1 Recognize factitious disorder (Table 35-1)

2 Differentiate factitious disorder from conversion disorder and malingering

3 Understand the best approach to patients with factitious disorder

she undoubtedly injects herself Specifically, although her insulin levels are

increased, her serum C-peptide levels are decreased When confronted, she becomes hostile and defensive and asks to leave the hospital No obvious external incentives are present Thus, it appears that her motivation is merely

to be sick as primary gain The fact that the patient consciously created the hypoglycemia rules out the diagnosis of a somatoform or conversion disorder The absence of a secondary gain differentiates factitious disorder from malin­gering It is useful to note that she is an intelligent woman who works in the health care field, a common scenario for this disorder

Table 35-1

DIAGNOSTIC CRITERIA FOR FACTITIOUS DISORDER

Intentional production or feigning of physical or psychological signs or symptoms The motivation is to assume the sick role (primary gain)

External incentives for the behavior (as in malingering) are absent

287

CLINICAL CASES

APPROACH TO FACTITIOUS DISORDER

Definitions

Pseudologia phantastica: The telling of "tall tales," or lying, commonly

seen in factitious disorder

Miinchhausen syndrome: Factitious disorder, especially involving

repeated episodes, seeking admission at different hospitals, and pseudologia phantastica

Miinchhausen syndrome by proxy: Factitious disorders induced in chil­

dren by parents, who are usually very cooperative after taking them to the hospital

Clinical Approach

Although the true incidence of this disorder is unknown, it seems to be more common in hospital and health care workers The etiology is unclear and can have to do with poor parent-child relationships during childhood Affected individuals usually have average to above-average intelligence, poor self-identity, and strong dependency needs They feign physical symptoms so con­vincingly that they are hospitalized or operated on

Differential Diagnosis

The possibility of an authentic underlying medical cause with an unusual pres­entation should be ruled out In addition, given the self-inflicted nature of the symptoms, it is essential that the patient be examined for any legitimate com­plications as well Examples include adhesions resulting from frequent (unnecessary) abdominal surgeries leading to obstruction, serious infections produced by the injection of urine or feces into the veins, and coma caused by hypoglycemia

Differentiating factitious disorder from conversion and other somatoform disorders, as well as malingering, can be difficult Whereas the etiology of the compulsion to fabricate physical or psychiatric illness is likely rooted in

unconscious, primitive dynamics, in factitious disorder the conscious moti­

vation is to assume the sick role Patients consciously feign illness in order

to be taken care of in a health care setting This behavior is in contrast to

that seen in conversion and other somatoform disorders, in which both the

underlying conflicts and the production of the symptoms are unconscious In

malingering, both the motivation (an external incentive) and the fabrication are

conscious

Patients with factitious disorder can also meet criteria for borderline per­sonality disorder Patients with both disorders frequently have histories of childhood mistreatment such as physical, sexual, or emotional abuse

288 CASE FILES: PSYCHIATRY

Treatment

There is no treatment per se for factitious disorders If there is an underlying psychiatric disorder such as major depression or an anxiety disorder, it should be treated as indicated Like patients with somatoform disorders, these individuals are extremely resistant to mental health treatment When discovered, they usually flee the hospital, frequently repeating the same or a

similar cycle at another facility Managing this disorder is more appropriate than treating it Liaison with a psychiatric consultation service is helpful in

engaging the patient in psychiatric treatment, as is working with the hospi­tal staff to cope with the feelings of anger, betrayal, and mistrust that fre­quently come to the forefront It is useful to keep in mind that individuals with factitious disorder are very ill and that, like other "genuine" patients, they require help and caring

Comprehension Questions

[35.1J Which of the following is most likely the motivation behind the behavior displayed in factitious disorder?

A Desire to avoid jail

B Desire to be taken care of

C Desire to obtain compensation

D Desire to obtain narcotics

[35.2] Which type of personality disorder is most likely to occur comorbidly with factitious disorder?

A Lying about back pain to receive time off from work

B Pseudoseizures in the context of a family conflict

C Placing feces in urine to receive treatment for a urinary tract infection

D Recurrent fears of having a serious illness

[35.4] Which of the following is the most useful approach for patients with factitious disorder?

A Confronting their feigning of symptoms

B Discharging them from the hospital

C Establishing a therapeutic alliance

D Referring them to legal authorities

[35.2] C Borderline personality disorder is not uncommon in patients with factitious disorder Individuals with either of these disorders often have similar histories of abuse, molestation, and emotional neglect Patients with borderline personality disorder also act out their internal psycho­logical conflicts on an interpersonal level, and they display the chaotic, labile affective state seen in factitious disorder

[35.3] C The hallmark of factitious disorder is intentional feigning of a phys­ical or psychiatric illness in order to assume the sick role Examples include injecting oneself with insulin to create hypoglycemia, taking anticoagulants to fake a bleeding disorder, and contaminating urine samples with feces to simulate a urinary tract infection Lying about back pain in order to avoid work is an example of malingering Pseudoseizures are an example of a conversion disorder Fear of hav­ing a serious disease caused by misinterpretation of bodily sensations

is characteristic of hypochondriasis

[35.4] C Although there is no specific treatment for factitious disorder, the best way to help these patients is to attempt to establish a therapeu­tic alliance and a working relationship Although this can be diffi­cult, only then can the patient's compulsion to feign illness be addressed and dealt with in a psychotherapeutic environment Confrontation is necessary in some circumstances, but if an accusa­tory or judgmental manner is employed, patients flee care and begin the cycle again at another hospital Prematurely discharging patients from the hospital or referring them to legal services has the same result, although in cases of factitious disorder by proxy (where a caretaker simulates illness in a child), referral to child protective services is necessary because this behavior is considered a form of child abuse

290 CASE FILES: PSYCHIATRY

C L I N I C A L P E A R L S

Factitious disorder is characterized by the intentional production of physical or psychiatric signs or symptoms in order to assume the sick role

Factitious disorder is more common in women and in those in the health care professions

The course of factitious disorder is chronic, with a pattern of lying, self-inflicted injuries, repeated hospitalizations, and premature discharges

The best management of factitious disorder involves early identifi­cation, avoidance of unnecessary tests and treatments, empathic understanding of the need to be sick, establishment of a thera­peutic working relationship, and potential referral to a mental health professional

•> CASE 36

The 2'/2-year-old, first-born son of married parents is brought to a pediatri­cian's office by his father Before this visit, the patient visited the pediatrician only for regular well-child checks and for treatment of one episode of otitis media The father is concerned about the behavioral problems his son has developed He reports that for the past month, after the patient goes to bed and

to sleep, the parents hear him get up in the middle of the night This behavior occurs perhaps once or twice a week On these occasions, the child is found standing somewhere in the house, crying and seemingly disoriented with rapid breathing and profuse sweating When the parents attempt to comfort him or return him to his room, he becomes quite upset, striking out at them and screaming loudly He continues to scream and fight for several minutes but then stops spontaneously If he can be awakened, he will continue to act fright­ened and cannot share any dream content Once the child is calmed, the par­ents put him back in his bed and he sleeps through the rest of the night without incident In the morning, he wakes up in his usual happy mood and does not remember what occurred the previous evening The parents are worried that he might be having seizures or developing a severe behavioral problem

• What is the most likely diagnosis for this child?

• What treatments would you recommend for this child?

292 CASE FILES: PSYCHIATRY

ANSWERS TO CASE 36: Sleep Terror Disorder

Summary: The patient is a 272-year-old boy with new-onset sleep problems

who has no significant other history He wakes at night, screaming with auto­nomic hyperarousal, and his parents are unable to soothe him These episodes last a few minutes, after which he goes back to normal sleep The child has no memory of the events in the morning

• Most likely diagnosis: Sleep terror disorder

• Recommended treatments: Protect the child from injury and do

nothing The disorder is usually time-limited

Analysis Objectives

1 Recognize sleep terror disorder in a patient (Table 36-1)

2 Offer treatment suggestions to the parents

Considerations

This patient's presentation is typical for sleep terror disorder, a disorder that is

found in 3% of all children and less than \% of adults and typically manifests

itself as emotional and behavioral disturbances at night These events usually

occur early in the nightly sleep cycle during delta (slow-wave) sleep With sleep terror disorder, the affected child does not remember the episodes in the morning Fever, sleep deprivation, and central nervous system depres­ sants may increase frequency of sleep terror episodes Typically, these children have no psychopathology The episodes are usually self-limiting

without treatment, and the prognosis is very good Reassuring the parents is the usual indicated intervention Nightmares occur during rapid eye movement (REM) sleep and are typically associated with the report of a "bad dream." If the child is awakened, he or she can typically recall the dream, even the next morning

Table 36-1

DIAGNOSTIC CRITERIA FOR SLEEP TERROR DISORDER

Patient is often unresponsive to efforts to soothe or calm

Little memory of episode in the morning after a normal awakening

293

CLINICAL CASES

APPROACH TO SLEEP TERROR DISORDER

Definitions

Delta sleep: Sleep stage characterized by low frequency (0.5 to 2 waves/

sec), high voltage (amplitudes greater than 75 microvolts) waves in at least 20% of the waves

Dysomnias: Sleep difficulties associated with the duration and type of sleep Parasomnias: Sleep disorders associated with problems during the stages

of sleep

Rapid eye movement: A sleep stage characterized by fast eye movements

and a wakeful pattern of electrical activity in the brain

Sleep cycle: The brain-wave activity associated with varying stages of

sleep from light to deep

Delta sleep: The EEG shows low frequency, high voltage waves Delta sleep has been divided into Stages 3 and 4 by some, depending on the number

of delta waves seen

Rapid eye movement: Low, fast voltage on the EEG, no muscle tone (cata­plexy), and very rapid eye movements

The sleep cycle is a dynamic presentation of the stages in a typical night's sleep Sleep disorders are classified and defined based on their occurrence and manifestation in the context of the sleep cycle Dyssomnias are disorders char­acterized by excessive sleepiness or difficulty initiating or maintaining sleep They include such intrinsic sleep disorders as narcolepsy and obstructive sleep apnea, and such extrinsic sleep disorders such as poor sleep hygiene, allergies, and insufficient sleep Parasomnias are sleep disorders that occur during sleep

or on arousal They include such disorders as sleep terrors, sleepwalking (som­nambulism), rhythmic movement disorder, sleep talking, nightmares, sleep paralysis, bruxism, and enuresis

294 CASE FILES: PSYCHIATRY

Individuals with nightmare disorders have dreams of a very frightening nature characterized by limited verbalization and movement These dreams occur during REM sleep, and the patient can often recall them in detail on awakening The absence of screaming and thrashing, plus the detailed memory

295

CLINICAL CASES

of the dream, differentiates this disorder from sleep terror disorder Patients with posttraumatic stress disorder may have frightening dreams or dissociative experiences, because this disorder is one of autonomic reactivity and an exag­gerated startle response following exposure to a traumatic experience However, these patients typically remember frightening dreams and/or flash­backs that do not occur exclusively at night Temporal lobe epilepsy is a type

of seizure disorder that includes active, often violent, motor responses, but these typically occur during waking hours

Perhaps one of the most common disorders of sleep in childhood is enuresis The treatment of enuresis in childhood is best approached by diagnosing the core problem correctly and advising the parents to be supportive of and not punish the child Primary enuresis is defined as nighttime urination in

a child with no previous significant period of dryness Secondary enuresis

is nighttime urination following a period of dryness (usually at least sev­ eral months) Secondary enuresis is often the result of a physical problem,

such as a urinary tract infection, or a psychological stressor, such as regression associated with the arrival of a newborn sibling

Primary enuresis can be treated in a number of ways, although the devel­opmental level of the child should also be considered It often remits sponta­neously as the child becomes older Generally, pharmacologic or extensive

behavioral treatment should not be considered prior to age 7 The behavioral treatment for enuresis primarily involves the use of an enuresis alarm, alter­ natively known as a "bell and pad." This device consists of a moisture-

sensitive sensor attached to the child's underwear and an alarm linked to the sensor close by When the sensor is activated, the alarm goes off, waking the child as well as the caretaker The child should then be quickly and directly taken to the bathroom to urinate This method of enuresis control has a 75% success rate, as well as a low rate of recidivism after the alarm is taken away Buzzer ulcers sometimes can develop and should be discussed as a potential adverse effect

Desmopressin (DDAVP) is a synthetic analog of a natural antidiuretic

hormone that has been found effective in 18 randomized, controlled trials A study comparing bell-and-pad method to DDAVP found comparable efficacy: bell-and-pad, 86% and desmopressin, 70% It was used successfully in both